After complaining of abdominal pains, he was referred to a gynecologist in April 2010. She found multiple polyps in his uterus and recommended a hysterectomy.

MacDonald said many women in his family have had to undergo similar procedures.

“Given my family history, it was either then or a few years down the road,” he said.

“From the initial consultation, right until the day after the surgery, no one had made any mention that it wouldn’t be covered or that I would have to pay,” he said. “I felt like a second-class citizen.”

There was also confusion about who would pay for the followup care. MacDonald was forced to have a family member remove some surgical staples that normally would have been taken out at the hospital 10 days after the surgery.

MacDonald filed an appeal with the insurer, but the province came to the same conclusion as the hospital.

Kathryn Dumke, MacDonald’s lawyer, said the decision is clearly discriminatory.

“He simply relied on what was recommended by the surgeon,” Dumke said. “There has never been a denial of coverage for a female-identified woman for this procedure. It was only because MacDonald is transgender that this is a problem.”

MacDonald filed a complaint against Medical Services Insurance, the province’s health insurer, and the case is now before the Nova Scotia human rights commission.

If the two sides can’t come to an agreement, the case will be heard before a human rights tribunal. Dumke said she doesn’t anticipate an easy solution.

“At the moment, there is no indication that this might be settled,” she said.

Nova Scotia’s medical insurer and MacDonald’s doctor did not return requests for comment.

Dumke said MacDonald’s experience points to wider problems with how transgender Canadians are treated by the health-care system.

“Generally speaking, trans health is in an abysmal state,” she said. “Many regular services will be scrutinized or denied because people are transgender. There’s an adverse climate in Canada for trans people attempting to deal with their health issues.”

MacDonald filed a consumer proposal, an alternative to bankruptcy, after receiving the $3,400 bill. He is now paying back the money in monthly installments, under protest.